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Chapter 1: Introduction

UnitedHealthcare Community Plan provides benefits and service to members, including:

•  TANF – Temporary Assistance for Needy Families

•  CHIP – Children’s Health Insurance Program

•  AABD – Assistance to the Aged, Blind, and Disabled

•  LTC – Long-term Care

•  DSNP – Dual Special Needs Plan

For More Information:

If you have questions about the information in this manual or about our policies, go to UHCprovider.com or call Provider Services at 888-980-8728.

For instructions on joining the UnitedHealthcare Community Plan provider network, go to UHCProvider.com. There you will find guidance on our credentialing process, how to sign up for self-service tools and other helpful information.

Whole Person Care Model

The Whole Person Care (WPC) program seeks to empower UnitedHealthcare Community Plan members enrolled in Medicaid, care providers and our community partners to improve care coordination and elevate outcomes. Targeting UnitedHealthcare Community Plan members with chronic complex conditions who often use health care, the program helps address their needs holistically. WPC examines medical, behavioral and social/environmental concerns to help members get the right care from the right care provider in the right place and at the right time.

The program provides interventions to members with complex medical, behavioral, social, pharmacy and specialty needs, resulting in better quality of life, improved access to health care and reduced expenses. WPC provides a care management/coordination team that helps increase member engagement, offers resources to fill gaps in care and develops personalized health goals using evidence-based clinical guidelines. This approach is essential to improving the health and well-being of the individuals, families and communities UnitedHealthcare Community Plan serves. WPC provides:

  • Market-specific care management encompassing medical, behavioral and social care.
  • Extended care team including primary care provider (PCP), pharmacist, medical and behavioral director, and peer specialist.
  • Field-based interventions engage members, connecting them to needed resources, care and services.
  • Individualized and multidisciplinary care plan.
  • Assistance with appointments with PCP and coordinating appointments. The Clinical Health Advocate (CHA) refers members to an RN, Behavioral Health Advocate (BHA) or other specialists as required for complex needs.
  • Education and support with complex conditions.
  • Tools for helping members engage with providers, such as appointment reminders and help with transportation.
  • Foundation to build trust and relationships with hard- to-engage members.

The goals of the WPC program are to:

  • Lower avoidable admissions and unnecessary emergency room (ER) visits, measured outcomes by inpatient (IP) admission and ER rates.
  • Improve access to PCP and other needed services, measured by number of PCP visit rates within identified time frames.
  • Identify and discuss behavioral health needs, measured by number of behavioral health care provider visits within identified time frames.
  • Improve access to pharmacy.
  • Identify and remove social and environmental barriers to care.
  • Improve health outcomes, measured by improved Health Plan Employer Data and Information Set (HEDIS) and Centers for Medicare & Medicaid Services (CMS) Star Ratings metrics.
  • Empower the member to manage their complex/ chronic illness or problem and care transitions.
  • Improve coordination of care through dedicated staff resources and to meet unique needs.
  • Engage community care and care provider networks to help ensure access to affordable care and the appropriate use of services.

UnitedHealthcare Community Plan manages a comprehensive care provider network of independent practitioners and facilities. The network includes health care professionals such as PCPs, specialists, medical facilities, allied health professionals and ancillary service care providers. UnitedHealthcare Community Plan offers several options to support care providers who need assistance.

To refer your patient who is a UnitedHealthcare Community Plan member to WPC, call Provider Services at 888-980-8728.

Secure Care Provider Website

UnitedHealthcare Community Plan provides a secure portal to network care providers, facilities and medical administrative staff called Link at UHCprovider.com. This website offers an innovative suite of online health care management tools, including the ability to view all online transactions for UnitedHealthcare Community Plan members. It can help you save time, improve efficiency and reduce errors caused by conventional claims submission practices.

To access Link, the secure care provider website, go to UHCprovider.com and either sign in or create a user ID for Link. You will receive your user ID and password within 48 hours.

The secure care provider website lets you:

  • Verify member eligibility including secondary coverage.
  • Review benefits and coverage limit.
  • Check prior authorization status.
  • Access remittance advice and review recoveries.
  • Review your preventive health measure report.
  • Access the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) toolset.
  • Search for CPT codes. Type the CPT code in the header search box on UHCprovider.com, and the search results will display all documents and/or web pages containing that code.
  • Find certain web pages more quickly using vanity URLs. You’ll see changes in the way we direct you to specific web pages on our UHCprovider.com provider portal. You can now use certain vanity URLs, which helps you find and remember specific web pages easily and quickly. You can access our most used and popular web pages on UHCprovider.com by typing in that page’s vanity URL identified by a forward slash in the web address, e.g. UHCprovider.com/claims. When you see that forward slash in our web links, you can copy the vanity URL into your web page address bar to quickly access that page.

Provider Services

Provider Services is the primary contact for care providers who require assistance. It is staffed with representatives trained specifically for UnitedHealthcare Community Plan.

Provider Services can assist you with questions on Medicaid benefits, eligibility, claim decision, forms required to report specific services, billing questions and more.

Provider Services works closely with all departments in UnitedHealthcare Community Plan.

Network Management Department

Within UnitedHealthcare Community Plan, the Network Management Department can help you with your contract, credentialing and in-network services. The department has network account managers and provider advocates who are available for visits, contracting, credentialing and other related issues.

If you need to speak with a network contract manager about credentialing or contracting, email our Network Management Team at Hawaii_PA_Team@uhc.com.

Cultural Competency Resources

To help you meet membership needs, UnitedHealthcare Community Plan has developed a Cultural Competency Program. Linguistic and cultural barriers can negatively affect access to health care participation. You must help UnitedHealthcare Community Plan meet this obligation for our members.

UnitedHealthcare Community Plan offers the following support services:

  • Language Interpretation Line: Hawai‘i is the only state in the United States that has designated a native language, Hawaiian, as one of its two official state languages. To support this, we provide oral interpreter services 24 hours a day, seven days a week to our members free of charge. More than 250 non-English languages and hearing impaired services are available. If a UnitedHealthcare Community Plan member needs Interpreter Services, we prefer care providers use a professional interpreter.
    • To access a professional interpreter during regular business hours, contact the Provider Call Center at 888-980-8728. After hours you may contact 877-261-6608.
  • Sign Language Interpretation: We provide sign language interpretors for our members. Please call Provider Services at 888-980-8728.
  • Cultural member materials: We provide simplified materials for members with limited English proficiency and who speak languages other than English or Spanish. We also provide materials for visually impaired members.

Complementary and Alternative Healing Practices

Many cultures engage in traditional health practices such as holistic medicine, acupuncture, medicinal herbs, meditation, spiritual counseling, therapeutic massage or martial arts.

When developing a treatment plan for members, consider:

  • Asking the member if they take any treatments, medicines or herbs to help them stay healthy or as treatment for their condition
  • Inquiring whether the member has sought advice or treatment from friends, alternative healers or other practitioners
  • Acknowledging the member’s choice for consultation of spiritual or traditional practitioners in addition to prescribing more western forms of treatment

Care Provider Privileges

To help our members access appropriate care and minimize out-of-pocket costs, you must have privileges at applicable in-network facilities or arrangements with an in-network provider to admit and provide facility services.

This includes full admitting hospital privileges, ambulatory surgery center privileges and/or dialysis center privileges.

Direct Connect

Direct Connect is a free online portal that lets you securely communicate with payers to address errant claims. This portal has the ability to replace previous methods of letters, faxes, phone calls and spreadsheets. It also helps:

  • Manage overpayments in a controlled process.
  • Create a transparent view between care provider and payer.
  • Avoid duplicate recoupment and returned checks.
  • Decrease resolution timeframes.
  • Real-time reporting to track statuses of inventories in resolution process.
  • Provide control over financial resolution methods.

All users will access Direct Connect using Link. On-site and online training is available.

Email directconnectsupport@optum.com to get started with Direct Connect.

Compliance

HIPAA mandates National Provider Identifier (NPI) usage in all standard transactions (claims, eligibility, remittance advice, claims status request/response, and authorization request/response) for all health care providers who handle business electronically.

Evidence-Based Clinical Review Criteria and Guidelines

UnitedHealthcare Community Plan uses MCG Care Guidelines (formally Milliman Care Guidelines) for care determinations.

A full list of contact details can be found on the Hawaii Care Provider Manual.